Financial Issues Chapter 15

DAW 8

Generic not available on the market

define and explain the difference between HMOs, POS & networks.

HMO- Costs are covered inside but not outside of the network POS- the patient's primary care physician must be a member and costs outside the network may be partially reimbursed. PPO- Costs outside the network may be partially reimbursed and the patient's primary care physician need not be member.

Preferred Provider Organization (PPO)

Health-care network that reimburses expenses outside the network at a lower rate than inside the network and usually requires generic substitution.

point of service (POS)

Health-care network where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.

HMO (health maintenance organization)

Health-care networks that usually do not cover expenses incurred outside the network and often require generic substitution.

online adjudication

Most prescription claims are now filed electronically by online claim submission and online processing the technician uses the computer to determine the exact coverage for each prescription with the appropriate third party.

refills

Most third-party plans require that most of the medication has been taken before the plan will cover a refill of the same medication.

DAW 6

N/A

medicare

National health insurance for people over the age of 65 or older, disabled people under the age of 65, and people with kidney failure.

DAW 0

No DAW

RX BIN Number

Number or code identifying where to send the claim

RX PCN number

Number or code identifying which company processes claims

DAW 2

Patient requested brand

Third- party programs

Another party besides the patient or the pharmacy that pays for some or all of the cost of medication: essentially, an insurer

Member ID

Unique number sometimes same as Social Security number

CPT code 99606

Used for followup encounters and may be billed in 1-15 min increments

CPT code

Used when filling out CMS 1550. These dentifiers areused for billing pharmacist- provided MTM services

Medicare—Part D Prescription Drug Coverage

What covers Medication Therapy Management?

rejected claims

When a claim is not accepted, the pharmacy technician can telephone the insurance plan's pharmacy help desk to determine if the patient is eligible for coverage.

dual co-pay

When a lower copay applies to generic drugs and a higher copay applies to brand drugs

dispensing code

When brand name drugs are dispensed, numbers corresponding to the reason for submitting the claim with brand name drugs are entered in a ______________ indicator field in the prescription system.

Group number

identifies the employer of the insured individual

CPT code 9905

used for first encounter with a pt and may be billed in 1-15 minute increments

DAW 9

"Other" override

DAW 4

- generic substitution permitted, but generic not in stock

list 10 common reasons for third-party claim rejection.

1) Dependent exceeds plan's age limit 2) Invalid birth date 3) Invalid person code 4) Invalid sex 5) Prescriber is not a network provider 6) Unable to connect with insurer's computer 7) Patient not covered (coverage terminated ) 8) Refill too soon 9) Refills not covered 10) NDC not covered

Pharmacy benefit manager

A company that administers drug benefit programs for insurance companies, HMOs and self- insured employers

medicaid

A federal-state program for the needy

TRICARE

A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.

POS

A network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.

CPT 99607

An add on code to be used with 99605 or 99606 when additional 15 minute increments are spent

prior authorization

A requirement that your physician obtain approval from your health insurance plan to prescribe a specific medication for you. It is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.

deductible

A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.

Card issuer ID

A unique identifier for the health plan

prescription drug card

BIN, Plan code, Group code, Issuer, ID, Subscriber name, PCP, Copays, Help desk telephone number, DAW codes

DAW 5

Brand dispensed, priced as generic

prescription drug benefit

Cards that contain necessary billing information for pharmacies, including the patient's identification number, group number, and co-pay amount.

workers' compensation

Coverage for employees accidentally injured on the job.

CPT

Current Procedural Terminology

DAW 1

DAW handwritten on the prescription by the prescriber

co-insurance

Essentially an agreement between the insurer and the insured to share costs

Days Supply

Insurance plans have set limits for how much of a med can be dispensed atlast.

maintenance medications

Many managed care health programs require mail order pharmacies to fill prescriptions for maintenance medications

age limitations

Many prescription drug plans have age limitations for children or dependents of the cardholder.

Medication Therapy Management (MTM)

Medicare recipients that are taking multiple meds or have certain diseases get this service from Pharmacists. It is billed by the tech.

DAW 3

Pharmacist selected brand

coordination of benefits

Process to provide maximum coverage for health benefits when a patient has coverage by two plans.

DAw 7

Substitution not allowed - brand drug mandated by law

usual and customary (U&C) or Usual, customary, reasonable price

The MAC is often determined by survey of the ______________________ prices for a prescription within a given geographic area. This is also referred to as the _________________________ price for the prescription.

maximum allowable cost

The amount paid by the insurer is not equal to the retail price normally charged, but is determined by a formula described in a contract between the insurer and the pharmacy. The amount paid by the insurer is called.....

CMS 10114

The from used for providers to apply for a NPI number

patient identification number

The number assigned to the patient by the insurer that is indicated on the drug benefit card. If it does not match the code for the patient in the insurer's computer (with the same sex and other information) a claim may be rejected.

co-pay

The portion of the cost of prescriptions that patients with third-party insurance must pay

Prescription drug plans

Third party programs for medicare part D

formulary

a list of medications approved for use

Universal claim form

a standard claim form accepted by many insurers

tier

categories of medications that are covered by third party plans

patient assistance programs

programs offered by some pharmaceutical manufacturers to help need.

NPI

the code assigned to recognized health care providers, needed to bill MTM services

CMS-1500 Form

the standard form used by health-care providers to bill for services